Application of the Neuman systems model to teaching health assessment and nursing process
McHolm, Frances A
TOPIC. A nursing theory framework for teaching health assessment.
PURPOSE. To improve teaching of health assesment and nursing process to beginng-level baccalaureate nursing students.
SOURCES. The Assessment and Analysis Guideline Tool, published and unpublished literature, personal observation, and faculty feedback were used in tool development.
CONCLUSIONS. Faculty concluded that students who could envision the connection of the Neuman Systems Model and NANDA nursing diagnoses through the nursing process would be better able to understand the nursing model and choose appropriate nursing diagnoses for client care.
Keywords: Health assessment, Neuman systems model, nursing diagnosis, nursing process
The purpose of this project was to improve teaching of health assessment and nursing process to sophomorelevel baccalaureate nursing students. Based on the Neuman Systems Model (1989,1995) concepts were identified to be included on a data collection and analysis tool. The approved NANDA diagnostic labels (NANDA, 1994,1996) were reorganized to reflect the Neuman Systems Model as represented in the tool. Guidelines were provided to connect the Neuman Systems Model and NANDA nursing diagnoses through the nursing process through the use of this tool.
In 1994 the faculty of the Malone College Department of Nursing Canton, OH, adopted the Neuman Systems Model (Neuman, 1989, 1995) as the nursing model for the curriculum. Before this, the faculty used an eclectic model for the nursing curriculum. The faculty agreed with Neuman’s focus on wellness, wholism, and systems thinking as foundational to nursing student education. Neuman (1995) states that wellness for any client system (individual, family, group, or community) must be considered in relation to internal, external, or created environmental stressors and system reaction to stressors. Forces or influences that are intrapersonal, interpersonal, and extrapersonal in nature characterize the environment and may exert positive or negative effects on the system. When one evaluates a system from a wholistic viewpoint, five variables-the physiological, psychological, sociocultural, developmental, and spiritual-must be considered that “are not significantly connected except with reference to the whole” (Neuman, p. 8). The system has a central core of survival factors encircled by concentric rings of barriers (the flexible line of defense, the normal line of defense, and the lines of resistance), which act as boundaries to provide protection to the system (Fawcett, 1995; Neuman).
Neuman (1995) has viewed health as optimal system stability at any designated time. Health is understood to be on a continuum, with wellness and illness on opposite ends. Use of this model focuses the practice of nursing on promoting system stability through attainment, retainment, and maintenance of optimal wellness and wholeness. The concept of prevention as intervention provides a typology of nursing actions that relate to client system stability and protective barriers. Primary prevention as intervention involves actions that strengthen the client before a system reaction is assessed. Secondary prevention involves actions that treat assessed client symptomologies that occur after system reaction. Tertiary prevention involves actions that promote wellness after treatment. Neuman stated that by “keeping the system stable, the nurse creates a linkage among the client, the environment, health, and nursing” (Neuman, p. 33).
These basic concepts of the Neuman Systems Model help students use critical thinking, which includes logic, deduction, and induction. Moreover, the Neuman model encourages students to collect sufficient data within the framework of nursing rather than medicine. Students also learn from this model that client perceptions are an integral part of the nursing process and should be included in data collection and client outcome development (Neuman, 1995).
Before adoption of the Neuman Systems Model, the Malone faculty had used Gordon’s Functional Health Patterns as an organizing framework for implementing the assessment phase of nursing process in sophomorelevel nursing courses. The transition to the Neuman Systems Model led to the development of a new student clinical data collection tool, the Malone College Department of Nursing Assessment and Analysis Tool, based on the format suggested by Neuman (1995). This new Assessment and Analysis Tool (see Table 1) included a client profile (see Figure 1); stressors as perceived by client and caregiver; and intrapersonal, interpersonal, and extrapersonal factors. The intrapersonal factors included the five variables (physiological, psychological, sociocultural, developmental, spiritual) identified in the Neuman model. To help students focus on pertinent data, the physiological variable was further delineated to include sections titled Oxygenation, Circulation, Neurosensory, Nutrition and Fluids, Elimination, Safety, Rest and Sleep, Comfort and Pain, Hygiene, Skin Integrity, and Sexuality/Reproductive.
The use of these more definitive concept categories under the physiological variable was modeled initially after an assessment and intervention tool used by the Department of Nursing at the University of Tennessee at Martin (1991). The Malone College Assessment and Analysis Tool also included an analysis sheet for clustering stressors and identifying related resources and strengths, as well as identifying nursing diagnoses, boundary lines affected (the flexible line of defense, the normal line of defense, and the lines of resistance), and priority rating of the problem.
The Assessment and Analysis Guideline Tool
Rationale. Faculty who introduced health assessment and nursing process to sophomore nursing students concluded that students also needed a guide to know what data to collect that exhibit the various dimensions of the client system, with an example of where they should record collected data. Faculty determined that suggestions for completing the analysis sheet would be helpful for students beginning to use the Neuman Systems Model and the Malone College Assessment and Analysis Tool. In addition, faculty ascertained that students who could envision which nursing diagnoses were pertinent to the data in specific categories would be better able to select appropriate diagnostic labels to guide the rest of their care plan. To achieve these aims, the Assessment and Analysis Guideline Tool was developed. This tool included suggested assessments, guidelines for completing data cluster analysis, and a listing of nursing diagnoses classified according to categories on the Malone College Assessment and Analysis Tool.
Method and description. Initial ideas for assessments, analysis, and classification of nursing diagnoses were identified on a working document. The first part of the Guideline Tool was developed by identifying pertinent assessments to include under each Neuman category (see Tables 2-4). To identify the assessments for each category, the authors first independently jotted down ideas (from their own experience) that would pertain to each category. For example, under the intrapersonal physiological factor of Oxygenation, it is suggested the student include subjective data, such as recent changes in ability to do normal daily activities and leisure activities and history of breathing problems (coughing, wheezing, shortness of breath). Suggested objective data included chest shape, respiratory pattern, and thoracic expansion. The authors then compared and discussed their data and consulted the definitions and concepts of the Neuman Systems Model as described by Neuman (1989,1995). Once the types of data to be included under each category were determined, various assessment texts (Barkauskas, Stoltenberg-Allen, Baumann, & DarlingFisher, 1994; Gordon, 1982, 1987, 1993; Jarvis, 1992, 1996; Weber, 1988, 1993) were consulted to determine if any additional data should be included.
After these steps, the Guideline Tool was circulated to the rest of the nursing faculty for their feedback and suggestions. Revisions made as a result of feedback are described below. It should be noted that the guidelines suggest the type of data to be identified, not the assessment questions or techniques to elicit the data.
The original Guideline Tool was developed to identify assessments for which students on the sophomore level would be held responsible. Additional assessments for junior and senior students were added in separate sections on subsequent editions of the tool as the students progressed through the curriculum. The Assessment and Analysis Guideline Tool as presented on the sophomore level is the form discussed and illustrated here.
The second part of the Guideline Tool gives suggestions for completing the Analysis Sheet (see Table 5). The instructions for completing the analysis of data were adapted from class content developed to teach students how to move inductively from data clusters to nursing diagnoses. In the “Stressors” column students are encouraged to record data that have been grouped in clusters and point to a particular problem. In the “Resources/Strengths” column they are told to record resources and strengths related to the problem identified in the cluster, which may be helpful in addressing the problem. In both of these columns the student is reminded that data relating to intrapersonal, interpersonal, and extrapersonal aspects should be included as appropriate. The next column across the page provides a place for recording the NANDA nursing diagnosis, which appropriately labels the problem identified by the data cluster. Students are encouraged to state the problem in their own words, attempt to select the diagnostic label closest to expressing the problem, then compare it with the definition and defining characteristics of the nursing diagnosis to confirm the most appropriate NANDA diagnosis label.
Each diagnostic statement also is to include a related factor. A related factor influences or contributes to the current health state being described in the nursing diagnosis label (Carpenito, 1997; NANDA, 1996). Usually the related factor states an element that a nurse can legally treat; it gives clear direction to selection of nursing interventions. In the column labeled “NSM Boundary Lines” and “Priority #,” students are instructed to identify which Neuman Systems Model boundary lines are impacted by the problem. An additional column is provided to indicate the priority of the problem based upon that boundary line.
The third part of the Guideline Tool lists the 1995-1996 NANDA (1994) nursing diagnosis labels classified according to the same categories as listed on the Assessment Tool. It was felt that such a list would facilitate the selection of appropriate nursing diagnoses and further support understanding of the concepts of the Neuman Systems Model. The authors again worked independently to classify the diagnoses and then compared and discussed their decisions, referring to the Neuman model to clarify concepts and definitions, and review from the department faculty. Suggestions from faculty resulted in risk for trauma, risk for injury, and risk for violence being added to the extrapersonal category of Employment.
In the final form of the classification, some diagnoses were included under more than one assessment category due to the overlap in definitions and defining characteristics, but these were flagged with an asterisk for clarity. For example, the nursing diagnosis fatigue was included under both Neurosensory/Movement and Rest/Sleep. An annotation also reminds the student that some diagnoses might be classified differently when the client system is a family. On the sophomore level, the client usually is an individual and, therefore, nursing diagnoses such as altered family processes and ineffective family coping are classified under the interpersonal category of “Family.” However, because the Neuman Systems Model allows the flexibility of addressing a single client, group, or groups as the focus of nursing concern (Neuman, 1989,1995), diagnoses that describe family phenomena such as those above may more appropriately be classified as intrapersonal when the family is the client system being addressed. For the family-as-client, the appropriate data and nursing diagnoses to include under the intrapersonal category of “Family” might include extended family.
It is interesting to note that the process of classifying the NANDA nursing diagnoses according to the Neuman Model categories facilitated clarification and revision of the categories on the original Malone College Assessment and Analysis Tool. The categories under the intrapersonal category of “Physiological” originally were adapted from the assessment tool developed by the University of Tennessee at Martin Department of Nursing (1991). The more definitive categories were included in the Malone tool to prompt students to collect systematically comprehensive data regarding the physiological client variable. Revisions to these categories were prompted by difficulty in classifying NANDA diagnoses concerning body temperature such as risk for altered body temperature, hypothermia, hyperthermia, and ineffective thermoregulation. To accommodate these diagnoses, the category titled “Nutrition and Fluids” was changed to “Nutrition/Metabolism.” Similarly, difficulty classifying the diagnoses of knowledge deficit, health-seeking behaviors, and ineffective management of therapeutic regime resulted in the category of “Safety” being changed to “Safety/ Health Maintenance.” In order to provide congruency in the category labels, “Neurosensory: Neuro and musculoskeletal” was changed to “Neurosensory/Movement.” To provide further clarification and to prompt students to collect the various types of data pertinent to this category, subcategories were developed for this part of the tool, which were labeled “Mobility,” “Cognitive,” and “Perception/Sensation.” The original category of “Comfort/Pain” was deleted. Suggested corresponding assessments on the Guideline Tool were modified accordingly.
Case Example of Guideline Tool Usage
The first nursing process assignment for sophomore students in the Malone program involves working with data from a case study about a 19-year-old female college student named Carla visiting the nurse at the school health center. In the case study, Carla has many concerns that include complexion problems, a disrupted relationship with her boyfriend, lack of exercise, a diet high in junk food, frequent cough and headache, difficulty dealing with the time pressure of getting school assignments completed, not getting enough sleep, not participating in usual religious activities, and difficulty in adjusting to living on campus. Use of the Guideline Tool is illustrated by tracing the steps of data clustering, analysis, and selecting a NANDA nursing diagnosis used by a student in completing this assignment.
First, all the data presented in the case study are entered under the appropriate Neuman category. Recording of data was facilitated by use of the suggested assessments on the Guideline Tool. For example, the student included the data, “Eats two meals a day, snacks throughout the day, likes fruits, vegetables, burgers, fries, pizza, ice cream; frequents local fast-food places; eats marshmallows and diet drink for breakfast; sometimes buys apples at local grocery; height, 5’6″, weight 155 pounds” as data under the intrapersonal category of Nutrition/Metabolism. Data recorded in the intrapersonal category of Neurosensory/Movement under Mobility included, “Rides bike and walks dog in summer; currently not exercising due to time spent studying.” Psychological data included, “Feeling bogged down with reading and assignments; states feels she doesn’t have time for anything but studying; states usually upbeat but not feeling happy lately; states feels blue.” Data noted under the intrapersonal category of Spiritual included, “States God has been important in life; has not been attending church due to increased time spent studying; states not feeling close to God like she used to; states wonders if God really cares about her and her situation.”
Data recorded under the interpersonal category of Family revealed, “Family lives 4 hours from school; family supportive but does not see them much due to distance; family very involved in participation in church services and activities.” Data under the extrapersonal category of Community Facilities included, “Lives on college campus; campus counseling center, health center, and pastoral offices available; student-led spiritual services occur during the week, which Carla has attended occasionally; a church similar to Carla’s home church located five blocks from the school; campus fitness center available to students; student participates in campus food plan for meals; transportation to local grocery available.” Delineating the intrapersonal, interpersonal, and extrapersonal factors helped the student to see the environmental context of Carla’s situation. Comparing the available data to the suggested assessments also enabled the nursing student to identify gaps in the data and what additional data needed to be collected in an actual client situation. For example, the case study included no data about Carla’s elimination status.
From the Neuman assessment database the student clustered data that pointed to eight specific problems and listed the data together in groups on the Analysis Form in the Stressors column. One stressor cluster involved the data: “States has not been attending church due to increased time spent studying; states not feeling close to God like she used to; states wonders if God really cares about her and her situation; states feeling bogged down with reading and assignments; states feels doesn’t have time for anything but studying; states usually upbeat but not feeling happy lately.”
In the Resources/Strengths column the nursing student listed the intrapersonal strengths that Carla had attended church in the past and that she had felt close to God in the past. Interpersonal resources listed were “the campus pastor, home church pastor, minister at the local church, family very involved in church activities, and fellow students who attend the campus spiritual services.” Extrapersonal resources noted were “the local church, the home church, the campus spiritual meetings, and the campus pastoral and counseling centers.”
Putting the problem in her own words, the student felt the data pointed to Carla’s feeling separated from God due to lack of contact with usual spiritual activities, being away from home, and feeling the pressure to spend all her time studying. This led her to consult the list of nursing diagnoses classified according to the Neuman categories and to identify two potential diagnoses concerning spiritual state: spiritual distress and potential for enhanced spiritual well-being. Having compared the definition and the defining characteristics of these diagnoses in a nursing diagnosis handbook (Carpenito, 1997), the student determined that the diagnosis spiritual distress related to lack of involvement in usual spiritual activities secondary to time pressure and distance from home was the most accurate nursing diagnosis. Because this was an actual problem, the Neuman Model Lines of Resistance were involved. The student gave this problem a high priority rating given the impact of this type of problem on resolving the other health problems Carla was experiencing. While the preceding is an example of use of data from a case study, the sophomore students have used the Guideline Tool in a similar manner with clients in the clinical setting.
Evaluation of the Guideline Tool
Advantages. The Assessment and Analysis Guideline Tool has been used with students for the school years 1995-1996 and 1996-1997. A major advantage in using the tool is that it assists students in collecting comprehensive data for each aspect of the client system. Informal feedback has indicated that students have found the tool helpful in knowing which data to collect to address the various parts of the client system. Given the opportunity to evaluate the Guideline Tool, students have stated, “[the tool] showed what type of data to collect and how specific to get. It helps me identify subjective, objective, and chart data.” Also, “[the tool] has helped me gain more stressors by doing more assessments, which make it easier to identify nursing diagnoses.” Other comments by students related to how the tool helped them understand the concepts of the Neuman Systems Model included, “It . . . helps me identify what strengths are intrapersonal and extrapersonal” and “it makes a clear picture of how many systems involve the well-being of the individual.” In addition, one teacher reported, “Since the tool clearly identifies what data should be included to address each dimension of the client system, it has been easier to see whether the students have the appropriate data.”
A second advantage to using the Guideline Tool is that it facilitates the process of moving inductively from data clusters to nursing diagnosis labels. In this way, the actual responses of the client to the health problem are considered rather than selecting nursing diagnoses according to the medical diagnosis. One student commented, “It helps me see stressors in all aspects of the person. This helps me formulate nursing diagnoses.” Students also have reported that the listing of nursing diagnoses according to the Neuman model helps them organize their thoughts and focus in on a smaller number of nursing diagnoses to determine which is the most accurate.
Further advantages of the Guideline Tool are that it helps students understand the major concepts of the Neuman Systems Model and clarify the relationships between the Neuman Model and NANDA nursing diagnoses. Students have commented that the Guideline Tool helps them focus on the various dimensions of the client situation: “It helps me put together stressors in [the] Neuman Model with NANDA diagnoses.” Faculty have noted that with the Guideline Tool, students collect more comprehensive data and grasp the relationships of the intrapersonal, interpersonal, and extrapersonal aspects of the client system quicker. They have agreed that by using the tool, students are more successful in identifying appropriate data and, therefore, in selecting appropriate nursing diagnoses.
Limitations. Some of the current limitations of the Guideline Tool are related to the design of the Assessment Tool. For example, the authors have discovered the tool does not fully portray intrapersonal, interpersonal, or extrapersonal aspects of the assessment data for each of the five variables (physiological, psychological, sociocultural, developmental, and spiritual). This limitation interfered with student appreciation of environmental factors that affect the client system. The analysis sheet also does not consistently delineate the intrapersonal, interpersonal, or extrapersonal aspects for stressors in the same way it does for resources and strengths of the client system. An additional limitation is that the Guideline Tool provides no guidance for writing outcomes, interventions, evaluations, and modifications as found on the Malone College Department of Nursing student nursing care plan form. Students have suggested that it would be helpful if the tool addressed primary, secondary, and tertiary aspects of care (intervention as prevention).
Plans include continuing to use the Guideline Tool and refining it according to student and faculty feedback. Consideration also will be given to how to redesign the Assessment Tool and analysis sheet to reflect more accurately the intrapersonal, interpersonal, and extrapersonal aspects for each of the five variables of the client system. In addition, a study is being designed to evaluate Guideline Tool use outcomes by replicating research done by Lowry (1995).
Understanding health assessment and nursing process is foundational to effective nursing practice. Through this project the authors have sought to assist nursing students to make the connection between a nursing model (the Neuman Systems Model) and NANDA nursing diagnoses through use of the Assessment and Analysis Guideline Tool. Understanding the aspects of the client system makes the students better able to use the Neuman Model to identify nursing approaches that prevent health problems, as well as those that assist the client who has health problems to achieve the highest possible level of wellness. The authors believe that by providing this guideline for application of the concepts of a nursing approach to data collection, analysis, and identification of problem labels, students will be able to provide appropriate, wholistic care as professional nurses.
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Frances A. McHolm, MSN, RN, and Kathleen M. Geib, MSN, RN, are Associate Professors, Department of Nursing, Malone College, Canton, OH.
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